Asymptomatic Gastroesophageal Reflux Disease
I am a 37-year-old surgeon. I discovered this week through endoscopy and esophagogastroduodenoscopy (EGD) that I have a 4-cm hiatal hernia. I don't have reflux and with clinical treatment I do not have symptoms. I would like to know if surgery is indicated or if the first line of care is medical treatment.

Marcelo Noronha de Rezende, MD

It depends on the type of hiatal hernia. Hiatal hernias are usually of the sliding type (type 1). The remainder consist of paraesophageal hernias. Type 2 hernias contain gastric fundus that has migrated into the mediastinum through the esophageal hiatus. Type 3 hernias contain both the fundus and the gastroesophageal junction within the sac. Initial diagnosis is made by chest radiograph or barium swallow. Given the association of reflux with hiatal herniation, preoperative EGD and esophageal manometry are appropriate.

In asymptomatic or medically controlled patients, sliding hiatal hernias must be distinguished from paraesophageal hernias when considering the risks and benefits of nonsurgical management. Patients with paraesophageal hernias (types 2 and 3) are believed to have an increased chance of gastric incarceration and strangulation. However, patients with sliding (type 1) hernias are not believed to be at increased risk for these complications; therefore, decisions about surgical management parallel those for patients with gastroesophageal reflux disease (GERD).

Since no medical therapy diminishes the risk for the life-threatening complications of type 2 and type 3 hiatal hernias, prompt elective repair has been the standard of care for many years. Laparoscopic repair of paraesophageal hernias has been reported,[1-3] and series available in the literature[4-7] have shown that the risks of elective repair have improved. Still, surgeons must balance recommendations for operation against the actual likelihood of life-threatening complications, especially in elderly, debilitated patients. Allen and colleagues[8] followed 23 of 147 patients with "intrathoracic stomach" by observation alone, and found that only 4 developed progressive symptoms over a median follow-up of 78 months. Of these, 2 had elective repair and 1 died from aspiration. More notable in this study was that only 1 gastric strangulation occurred over 245 patient years. Therefore, we recommend elective repair for asymptomatic patients with significant life expectancy and symptomatic patients with acceptable perioperative risks, regardless of age.

When symptomatic, patients typically present with symptoms of GERD, especially dysphagia or chest pain. Thirty percent may develop a complication of the hernia, such as bleeding, obstruction, volvulus, strangulation, or perforation.

Although the set-up for laparoscopic paraesophageal hernia repair is similar to that for laparoscopic fundoplication, aspects of the case dramatically increase the degree of difficulty and the risk profile above that of fundoplication alone. Multiple adhesions commonly must be divided to reduce the hernia sac from the mediastinum. During this dissection, it is possible to injure the mediastinal pleura and the vagus nerves, which often are displaced from the esophagus. Once the sac is separated from the crura, it must be reflected out of the mediastinum and excised. A Collis gastroplasty may be necessary in cases of "short" esophagus. We prefer to close the hiatal defect posterior to the esophagus by reapproximating the diaphragmatic crura with interrupted, pledgeted, nonabsorbable sutures. Although use of prosthetic has been reported, we avoid its use because of the risk for excessive adhesion formation and the potential for esophageal erosion. We perform coincident antireflux procedures since persistent symptomatic reflux will occur in 20% of cases if fundoplication is not performed.